Wednesday, June 29, 2016

The American Civil War (a.k.a. The War Between the States) was long and terrible. Beginning in 1861, the four-year war is still the deadliest in American history with an estimated 620,000 soldiers killed and an indeterminate number of civilian casualties. Approximately ten percent of all Northern males and 30 per cent of all Southern males were killed in the fighting and the social and political costs left their mark on the United States for generations afterward.

As one of the first "modern" wars with heavy artillery and other weapons of mass destruction, physicians on both sides of the conflict were faced with unprecedented medical challenges in dealing with wounded soldiers. Military surgery was still in its infancy and antiseptic practices were largely unknown so casualties remained high despite the best efforts of doctors and nurses.

To deal with patient suffering, doctors relied on two medical innovations that had only become available a few years previously: the hypodermic needle and morphine sulphate. First developed in 1804, the opium derivative received its name from the Greek god of dreams, Morpheus, and widely advertised to physicians as a safe and effective analgesic. Given that surgery was often traumatic due to the lack of proper anesthesia, the use of morphine (spurred on by the development of the hypodermic needle in 1857) began to spread. Opium pills were also widely dispensed when hypodermic needles were unavailable. During the Civil War, solders were often dosed with enormous amounts of morphine or opium to kill the pain of amputations and other surgeries.

While the potential for addiction was already known at the time, simple humanitarian concerns ensured that soldiers remained liberally dosed with morphine and whatever other analgesics were available.

Anecdotal accounts of Civil War doctors on both sides dispensing opium seem descriptive enough. One Confederate doctor, William H. Taylor, gave a plug of opium to every patient reporting pain depending of whether or not they were constipated. A Union doctor, Nathan Mayer, diagnosed patients from horseback. If the wounded soldier needed morphine, Mayer would pour out an "exact into his hand and had the patient lick it off (not a recommended method, by the way).

Since medical epidemiology was still unknown, actual statistics relating to morphine addiction remain scarce. Some sources have suggested that as many as 400,000 veterans were left addicted to morphine due to their wartime experiences. These addicts were readily identified by the characteristic leather thong around their necks to which a small bag was attached. The bag carried a supply of morphine sulphate tablets as well as a hypodermic needle. Upon their discharge from the army, this was all that was given to the returning soldiers to ease their return to society (no Veterans' Administration services in those days). In recognition of the medical issues that these veterans faced, the term "Soldier's disease" was coined (as opposed to "Soldier's Heart" which was an early name for Posttraumatic Stress Disorder).

But how prevalent a problem was Soldier's Disease? As some historians have noted, there were few descriptions of widespread morphine addiction during the 19th century. The existence of thousands of morphine addicts in the United States following the end of the Civil War would have likely made far more of an impact than later medical authorities noted. Veterans certainly had good reason to conceal their addiction since public exposure might have cost them their service pension (drug addiction was not a recognized medical condition). The greatest social impact of the war and the addicts who survived it was likely from 1865 to 1900 when most addicts had died off.

While the explosive growth of opium addiction from 1865 to 1895 was certainly noted, the few drug addiction surveys undertaken during this period showed that women were more likely to be addicts than men. Many of these women addicts had become addicted to the opiates that had been legally prescribed for them by their physicians (often as treatment for "female problems").

Although 19th century newspaper editorials expressed alarm over substance use, it almost always focused on opium and the insidious "opium dens" which were seen as a threat to American society (there were often racist overtones to these editorials given that they focused on how "white women" could be ensnared into smoking with "Chinese men").

Despite concerns relating to morphine addiction (and the thousands of addicts who had supposedly been released into society after the war), physicians continued to prescribe morphine for their patients. As a catch-all medical solution for a wide variety of problems (which could range from headaches to diarrhea), hypodermic-wielding physicians likely created more addicts than the typical opium den. In an 1880 medical text titled The Hypodermic Injection of Morphia, the author stated that "here is no proceeding in medicine that has become so rapidly popular; no method of allaying pain so prompt in its action and permanent in its effect; no plan of medication that has been so carelessly used and thoroughly abused; and no therapeutic discovery that has been so great a blessing and so great a curse to mankind than the hypodermic injection of morphia".

Not only did the demand for morphine create a steady market for the drug, it also created a strong demand for hypodermic needles as well. The 1897 Sears and Roebuck catalogue advertised a hypodermic kit (including a syringe, two needles, two vials, and a carrying case) for a mere $1.50 (quite a bargain, really). Patent medications, largely unregulated at the time, were advertised for the treatment of a wide variety of complaints and, naturally, morphine and opium were popular ingredients. The self-medication that these patent medications made possible certainly aggravated the problem of substance abuse but the lack of formal government controls helped drive sales.

It seems inevitable that alternatives to morphine would become available as medical researchers learned more about the chemical composition of opium. Codeine was first isolated in 1832 by French chemist, Pierre Robiquet, although it proved not to be as popular as morphine. The real breakthrough came in the 1870s when English chemist C.R.A. Wright first isolated the opiate compound that would later be marketed under the brand name of heroin. When Bayer Pharmaceuticals released their product some time later (the name heroin was taken from the German word for heroic, heroisch), it was billed as a perfectly safe alternative to morphine.

And heroin was hardly the only new product available. With the development of chloroform, nitrous oxide, and various other anesthetics, pain-free surgery and dentistry became all the rage. At the same time, however, there was a growing fear of the social dangers surrounding opiates (including morphine and heroin). Following the Spanish-American War and the American annexation of the Philippines in 1898, public alarm over opium addiction became even more widespread. As a result of U.S. pressure, the first International Opium Commission was held in Shanghai in 1909. A second meeting was held in 1911 and the first comprehensive policy regulating opiate use was signed.

In the United States, anti-drug lobbyists began agitating from more stringent safeguards. Hamilton Wright was appointed as America's first Opium Commissioner in 1908 and, after attending the Shanghai meeting, would comment that "Of all the nations of the world, the United States consumes most habit-forming drugs per capita. Opium, the most pernicious drug known to humanity, is surrounded, in this country, with far fewer safeguards than any other nation in Europe fences it with". Once again, drug abuse was linked to racial unrest as Wright went on to comment that "cocaine is often the direct incentive to the crime of rape by the Negroes of the South and other sections of the country" (while cocaine is not an opiate, the drug reformers insisted on classifying it as a narcotic as part of their platform).

Newspaper editors and academics alike weighed in on the dangers of drug addiction and the horrendous social costs involved. Racism was readily apparent and the editorials were filled with accounts of "drug-crazed, sex mad negroes" and "Chinamen" seducing white women on drugs. Various drug "experts" testified on the proliferation of drug-addicted "Negroes" stalking and attacking white women while under the influence.

By 1914, forty-six states had passed legislation regulating or banning opium, morphine, or heroin. The fact that World War One had just broken out in Europe became a factor as well since experts began raising concerns about the cases of Soldier's Disease that had arisen from the Civil War and the possibility of American involvement in the new year leading to more cases.

In 1915, Jeannette Marks published a highly influential article in the American Journal of Public Health describing the "hydra-headed drug curse" following the Civil War and expressed alarm that the problem would shortly resurface. She was also the first to suggest that there had been as many as 400,00 morphine addicts following the war although she was given to exaggeration (she had also estimated there being 4,000,000 drug addicts in the U.S. in 1915).

While other experts disputed her estimate, the consensus that drug regulation was needed seemed clear enough. After quiet deliberation, the Harrison Narcotics Tax Act was signed into law on December 17, 1914. Technically focusing on taxing narcotics (again, cocaine was included), the act also imposed still penalties for the sale and importation of all narcotics. Although morphine and other opiates could still be prescribed by a physician, the anti-drug era had begun in force.

As for Soldier' Disease, its popularity as a diagnosis began to level off during the 20th century when substance abuse in the military became better understood. Despite the role of the diagnosis in helping to shape U.S. drug policy and the numerous wars that have been fought in the past century, the use of a distinct diagnosis for returning soldiers addicted to pain medication has been largely discarded in the clinical literature. While drug experts continue to disagree on the actual number of Civil War morphine addicts (the estimates range from 45,000 to 400,000). Still, the controversy remains over how any valid estimate could ever be made given the lack of reliable data from that era.

What isn't in dispute however, is that substance abuse among military personnel continues to be a political minefield regardless of the actual medical needs of soldiers dealing with chronic pain or posttraumatic stress. Despite research initiatives by the National Institute on Drug Abuse and the Department of Veteran's Affairs, the substance abuse problems that returning soldiers face are still waiting to be solved.